Overcoming Barriers to Cardiac Rehab Enrollment Part 2: Addressing Cost, Patient Adherence and Access

Friday, January 15, 2021 | MedAxiom Consulting Team

In Overcoming Barriers to Cardiac Rehab Enrollment Part 1, I explained the benefits of cardiac rehab (CR) and the socioeconomic barriers that have caused an enrollment gap for patients that should participate as a part of their treatment plan. These barriers are well known and include health plan coverage, co-pay, patients’ commitment to follow-through, travel and in 2020 the pandemic – quite possibly the most crushing blow to the traditional CR model. It was also noted in part 1 that the influence of the cardiovascular provider can make a difference in how the patient views the importance of completing CR. As many are facing financial strains due to COVID-19 cost can be a major factor when deciding whether or not to enroll. If there isn’t any expectation of completion many will not participate.

In Part 2 of this series, I explore patient cost roadblocks and how financial assistance programs can provide solutions for patients that may otherwise choose not to participate. However, even after the patient decides to enroll patient adherence and access must be addressed. One thing that COVID-19 taught us is being able to meet patients where, when and how they are available is not just a convenience anymore but a requirement.

Patient Cost

When speaking with physicians, the healthcare team and patients, cost and adequate insurance coverage typically come in at, or close, to the top of the list of barriers to referral and enrollment. Medicare covers CR on a per session basis for up to 36 traditional sessions or up to 72 intensive cardiac rehabilitation (ICR) sessions. The traditional Medicare co-pay is applied for each session, making the estimated co-pay responsibility for Medicare patients in 2021 up to $835 for 36 traditional CR sessions and up to $1,670 for 72 ICR sessions. For Medicare patients who have supplemental insurance some portion of the co-pay responsibility may be covered, but supplemental coverage for the service and how much may be covered varies widely. Medicare Advantage (MA) plans do provide coverage for CR however the co-insurance responsibility varies widely across plans and geographies. Out-of-pocket responsibilities per session may be quite high for some MA plans, making costs to the patient prohibitive. Private and commercial payers may or may not cover CR and like MA plans, out-of-pocket responsibilities vary widely and may be particularly high. When covered, non-federal payers typically approve the same indications as those approved by Medicare. Out-of-pocket cost is a barrier for low- and fixed-income patients and it may deter referral if assisting patients to find access to financial assistance is complex and time consuming.

Financial Assistance Programs – Creating Solutions Upfront

Getting patients enrolled in CR makes sense clinically and financially for healthcare systems. The Million Hearts Cardiac Rehabilitation Collaborative work has quantified potential savings for patients completing 36 one-hour CR sessions as $4,950 – $9,200 per year of life. Because CR also helps to reduce readmissions in the cardiovascular population improving enrollment and completion rates can have a positive impact on value-based purchasing measures, third-party designations and publicly reported outcome measures.

It’s crucial to create easy and dignified solutions to address financial barriers to CR enrollment for the patient. An interest-free sliding scale payment plan for the CR program can be an option to assist with out-of-pocket expenses for low income and underinsured patients. Finding resources for uninsured patients may be more challenging, but work with patient financial services to establish self-pay rates and payment plans. Establishing charitable foundation endowments with fundraising is an excellent option to support uninsured patients who will benefit from CR, such as an annual fundraising campaign during heart month.

Assessing the need for assistance with out-of-pocket costs is an important aspect of counseling the patient to move forward with enrolling in CR. Design patient education about CR to provide clear direction about the steps needed to make crucial lifestyle changes. Show how CR is equally important as other interventions to reduce the chance of future events and the risk of mortality or disability related to future events. Provide assurance during the enrollment process that financial assistance is available and embed this information into the patient education material. When possible, avoid additional appointments with patient financial services by including the necessary forms and documents for financial assistance or payment plans in the admission process.

Improving Patient Adherence to CR

The strength of the physician’s recommendation is important to push patients toward enrollment and optimizing the CR program and infrastructure is important to mitigate potential socioeconomic barriers. Keeping patients enrolled and engaged in CR will be strongly influenced by the CR team. To support patients in maximizing the benefits from CR the team can evaluate current and historic program statistics and create strategies to establish an expectation for all patients to complete 36 sessions (72 sessions for ICR). This may be a cultural shift for your program but designing improvement to achieve new goals for the average number of sessions completed is important as a parallel to improving enrollment.


Work and family commitments, program capacity, location/travel distance, and operational hours complicate access to CR and create barriers to enrollment. A truly patient-centric approach to mitigating these types of barriers to enrollment requires an assessment of the socioeconomic demographics of the patient population served by your program. When possible, use both ambulatory practice data and acute care discharge data to create strategies to increase enrollment. For example, in tertiary programs partner with smaller community hospital-based programs closer to home for patients to coordinate referral and enrollment. If data reflect a substantial number of patients are working age, expanded hours of operation may be a solution for those patients or modify existing schedules to assure working patients receive priority for early or late sessions.

Learn more about the MedAxiom Consulting Team and how we can help you and your organization tackle issues such as patient access, effective leadership, staffing/operational efficiencies, adaptability and more.

Illustration: Lee Sauer

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